Table of Contents List of Abbreviations and Acronyms ..............................................................................II Message ................... ………………………………………………………………………………………………………IV Foreword ..................................................................................................................................V Executive Summary ............................................................................................................. 1 Background ............................................................................................................................3 • Introduction .................................................................................................................3 • Global Overview ..........................................................................................................3 • AMR situation in Pakistan .......................................................................................4 Vision of National Strategic Framework .......................................................................9 Strategic Framework Objectives .....................................................................................9 Definitions .............................................................................................................................10 Strategic Framework Statements based on WHO’s AMR Objectives ............... 12 Objective 1: Improve awareness and understanding of AMR through effective communication, education and training ...................13 Objective 2: Strengthen the knowledge and evidence base through surveillance and research ................................................................15 Objective 3: Reduce the incidence of infection through effective sanitation, hygiene and infection prevention measures ........ 17 Objective 4: Optimize the use of antimicrobial medicines in human and animal health ........................................................................................19 Objective 5: Develop the economic case for sustainable investment that takes account of the needs of all countries, and increase investment in new medicines, diagnostic tools, vaccines and other interventions ............................................................................. 21 Limitations ............................................................................................................................23 Way forward ..........................................................................................................................24 Acknowledgments .............................................................................................................25 References ............................................................................................................................26 Annexure 1: The process of Strategic Framework Development ................31 Annexure 2: Literature Review.................................................................................32 Annexure 3: AMR Containment System Assessment .....................................33 Annexure 4: SWOT Analysis .....................................................................................42 Annexure 5: Checklist-National Action Plan development support tools................52 Annexure 6: Provincial Health Structure and Roll out Plan .......................... 66 Annexure 7: AMR Surveys .........................................................................................67 Annexure 8: List of participants in workshops ...................................................70 I List of Abbreviations and Acronyms AFIP Armed Forces Institute of Pathology AMR Antimicrobial resistance ARI Acute Respiratory Infection ASP Antibiotic Stewardship Programs AST Antibiotic Susceptibility Testing CDC Centre for Disease Control, Atlanta CLSI Clinical and Laboratory Standard Institute DGHS Directorate General of Health Services DRAP Drug Regulatory Authority of Pakistan EARS- Net European Antimicrobial Resistance Surveillance Network EMRO Eastern Mediterranean Regional office (WHO) ESBLs Extended spectrum beta lactamases FAO Food & Agriculture Organization FELTP Pakistan Field Epidemiology and Laboratory Training Program GAP WHO Global Action Plan for AMR GLASS Global Antimicrobial Resistance Surveillance System HAIs Hospital-acquired infections HCWs Healthcare workers HCP Healthcare Professional ICC Inter-sectoral Core Committee IPC Infection Prevention &Control IHR International Health Regulation ICUs Intensive care units LIS Laboratory Information System MDR Multi-drug Resistant MDROs Multidrug-resistant organisms MIS Management Information System MMIDSP Medical Microbiology and Infectious Diseases Society of Pakistan II MNHSR&C Ministry of National Health Services, Regulations & Coordination MNFS&R Ministry of National Food Security and Research NARC National Agricultural Research Centre PARC Pakistan Agricultural Research Council NACP National AIDS Control Program Pakistan NIH National Institute of Health NGOs Non-Governmental Organizations NTP National TB Program OIE Organization for Animal Health OTC Over the counter PARN Pakistan Anti-Microbial Resistance Network PMRC Pakistan Medical Research Council PNC Pakistan Nursing Council PVMC Pakistan Veterinary & Medical Council TB Tuberculosis USAID United States Agency for International Development VAP Ventilator Associated Pneumonia WHA World Health Assembly WHO World Health Organization III Message AMR has emerged as a major public health problem worldwide leading to significant morbidity and mortality. The growing problem of AMR has resulted in significant health crisis in almost all the countries of the world including Pakistan, resulting in an alarming increase in the burden of infections due to multi-resistant organisms and severely limiting the choice of antimicrobial agents available for treatment. The emergence and spread of resistance among the micro- organisms is a complex phenomenon and hence requires multi-pronged approach to contain this phenomenon. Accordingly, the WHO through resolution WHA/67.25 in May 2014 stressed the need for development of Global Action Plan which reflects the global consensus on the profound threat of AMR to human and animal health. Accordingly, the 68th WHA through a resolution A68/20 adopted the Global Action Plan on AMR in May 2015. The Global Action Plan aims to ensure, for as long as possible, continuity of successful treatment and prevention of infectious diseases with effective and safe medicines that are quality-assured, used in a responsible way, and accessible to all who need them. The first follow-up action to the commitment of the Government of Pakistan was the development of the “National Strategic Framework for Containment of Antimicrobial Resistance”. In line with the five strategic objectives of the WHO Global Action Plan (GAP) for AMR, the Ministry has steered the development of National Strategic Framework for AMR Containment through a consultative process adopting “One Health Approach”. It is indeed a matter of appreciation that a broad range of stakeholders representing health, agriculture, livestock, environment, academia, armed forces and private sectors participated in the process of development of strategic framework. The national strategic framework addresses the five objectives of the GAP and includes; improve awareness and understanding of antimicrobial resistance; strengthen knowledge through surveillance and research; reduce the incidence of infection; optimize the use of antimicrobial agents; and ensure sustainable investment in countering AMR. The document also provides in-depth situation analysis of AMR in human and animal sector as well as a detailed analysis of strength, weakness, opportunities and threats (SWOT) of the five strategic objectives. The process also involved consensus building on the policy statements for each objective, which are now being translated into a comprehensive National AMR action plan with strategic, operational and monitoring/ evaluation framework that will be presented before the 69th World Health Assembly. The Government of Pakistan shall remain committed to the WHO resolutions on AMR as a responsible member state to comply with the global health security challenges. - Saira Afzal Tarar, Minister for State IV Foreword Emergence of Antimicrobial Resistance (AMR) is a complex phenomenon that follows use of antimicrobials and has been accelerated by inappropriate antimicrobial use. Higher consumption of antimicrobials especially antibiotics is associated with higher levels of resistance. Antimicrobial resistance (AMR) has emerged as one of the world’s most serious public health problems and WHO has called it as “The greatest threat to human health”. The growing AMR problem represents failure in public Strategic Framework, global governance, research prioritization and the market system at the global level. A number of microorganisms including bacteria, viruses, parasites that cause infectious disease no longer respond to common antimicrobial drugs. The factors responsible for AMR includes lack of knowledge on AMR, irrational/inappropriate use, lack of information and awareness on its proper use, absence of Strategic Framework on antimicrobial use, spurious, substandard, falsified, fake and counterfeit antimicrobials in the market and unregulated access and availability of all the antimicrobials over the counter without prescription. These factors are directly or indirectly related